Valve‐in‐valve transcatheter aortic valve replacement versus redo surgical aortic valve replacement: A systematic review and meta‐analysis

Abstract

Background/Aim: With the growing contemporary use of bioprosthetic valves, whose limited long-term durability has been well-documented, an increase in the need for reintervention is expected. We perform a meta-analysis to compare the current standard of care, redo surgical aortic valve replacement (Redo SAVR) with the less invasive alternative, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) for treating structural valve deterioration.Methods: After a comprehensive literature search, studies comparing ViV TAVR to Redo SAVR were pooled to perform a pairwise meta-analysis using the randomeffects model. Primary outcomes were 30-day and follow-up mortality.Results: A total of nine studies including 9127 patients were included. ViV TAVR patients were significantly older (mean difference [MD], 5.82; p = .0002) and more frequently had hypercholesterolemia (59.7 vs. 60.0%; p = .0006), coronary artery disease (16.1 vs. 16.1%; p = .04), periphery artery disease (15.4 vs. 5.7%; p = .004), chronic obstructive pulmonary disease (29.3 vs. 26.2%; p = .04), renal failure (30.2 vs. 24.0%; p = .009), and >1 previous cardiac surgery (23.6 vs. 15.9%; p = .004).Despite this, ViV TAVR was associated with decreased 30-day mortality (OR, 0.56; p < .0001). Conversely, Redo SAVR had lower 30-day paravalvular leak (OR, 6.82; p = .04), severe patient-prosthesis mismatch (OR, 3.77; p < .0001), and postoperative aortic valve gradients (MD, 5.37; p < .0001). There was no difference in follow-up mortality (HR, 1.02; p = .86).Conclusions: Despite having patients with an increased baseline risk, ViV TAVR was associated with lower 30-day mortality, while Redo SAVR had lower paravalvular leak, severe patient-prosthesis mismatch, and postoperative gradients. Although ViV TAVR remains a feasible treatment option in high-risk patients, randomized trials are necessary to elucidate its efficacy over Redo SAVR.

Use of a sutureless aortic valve in reoperative aortic valve replacement

“…This reduces the likelihood of PPM both in the Perceval and any future ViV reinterventions. 12 , 13 , 14 , 15 This stands in contrast to the outcomes of ViV TAVR in patients with small bioprosthetic valves, who suffer greater gradients, early consequences of PPM, and reduced 1-year survival. 12 , 13 , 14 , 15

Figure 3 Graphical abstract summarizing the hemodynamic outcomes of our patient cohort after Perceval placement during redo AVR.

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“… 12 , 13 , 14 , 15 This stands in contrast to the outcomes of ViV TAVR in patients with small bioprosthetic valves, who suffer greater gradients, early consequences of PPM, and reduced 1-year survival. 12 , 13 , 14 , 15

Figure 3 Graphical abstract summarizing the hemodynamic outcomes of our patient cohort after Perceval placement during redo AVR. Nearly all patients had a larger internal diameter ( ID ) valve implanted than what was explanted, which improved their gradients and allows for larger ViV TAVR implants in the future, altogether reducing the risk for PPM.

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“…ViV TAVR is an excellent strategy but is limited with uncertain long-term outcomes and may even be inappropriate in patients with small annuli. 12 , 13 , 14 , 15 In this new era of aortic valve surgery, choosing the correct patients to undergo either redo SAVR or ViV TAVR is critical in optimizing patient outcomes. We have shown that redo AVR with explant of the old valve and implant of a Perceval is a useful tool in dealing with degenerated aortic valves, especially in small annuli.…”

“…11 Multiple recent meta-analyses have compared outcomes between ViV TAVR and redo SAVR, generally revealing ViV TAVR to have improved 30-day mortality over redo SAVR, but with redo SAVR noting better postoperative gradients and less occurrences of severe patient–prosthesis mismatch (PPM). 12 , 13 , 14 This PPM difference was further investigated in the Valve-In-Valve International Data registry, which revealed significantly worse outcomes for patients with small annuli (≤21 mm) who underwent ViV TAVR, with a 1-year mortality of approximately 25%. 15 These patients with small annuli also had a 41.2% rate of significant PPM (mean gradient ≥20 mm Hg), nearly 2 times the rate in the rest of the cohort.…”

Decellularized versus cryopreserved pulmonary allografts for right ventricular outflow tract reconstruction during the Ross procedure: a meta-analysis of short- and long-term outcomes

“…Despite this, the operation’s use has dramatically decreased in the past decade due to operative complexity and fear of long-term durability [ 31 ]. This trend coupled with the advent of valve-in-valve technology [ 32 , 33 ] for patients requiring repeat aortic valve interventions greatly diminishes the hope of definitive randomized trials comparing the use of decellularized and cryopreserved allografts for RVOT reconstruction during the Ross procedure. Therefore, in the absence of high-evidence trials and larger, multicenter propensity-matched studies, our hope is that this review will provide some guidance for heart teams as they decide the optimal treatment approach for their patients.…”